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Concept Documentation Nutritional Care (Eng), Lecture notes of Nutrition

The process of documentation in nutritional care, including nutrition assessment and re-assessment, diagnosis, intervention, monitoring, and evaluation. It also defines documentation and its purpose, as well as the requirements for documentation. Various forms of documentation are also discussed. The document emphasizes the importance of clear, concise, and accurate documentation, and provides guidelines for healthcare professionals to follow. relevant for nutrition students and professionals.

Typology: Lecture notes

2021/2022

Available from 02/20/2023

AlinaHS
AlinaHS 🇮🇩

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CONCEPT DOCUMENTATION NUTRITIONAL CARE
Individual/Population Interacts with Nutrition Professional
a. Nutrition Assessment and Re-Assessment
1. Obtain or collect relevant data
2. Analyze or interpretation of collected data
b. Nutrition Diagnosis
1. P: Identify the Problem
2. E: Determine the Etiology or cause
3. S: Signs and symptoms
c. Nutrition Intervention
1. Define interventions and prescriptions
2. Formulate goals and determine actions
3. Implementing action
d. Nutrition Monitoring and Evaluation
1. Selects or identifies quality indicators
2. Monitor and evaluate diagnosis completion
Definition of documentation
Process of collecting, selecting, processing, and storage of information in the field of
knowledge
the provision or collection of evidence from information such as pictures, quotations,
newspaper, cuttings newspapers, and other reference materials
Purpose of documentation
Means of communication
As a responsibility
For statistical information
Education
Source of research data
Service quality assurance
Source of data for sustainable nutrition care services
As a provider of data / patient history for further treatment from other health teams
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CONCEPT DOCUMENTATION NUTRITIONAL CARE

Individual/Population Interacts with Nutrition Professional a. Nutrition Assessment and Re-Assessment

  1. Obtain or collect relevant data
  2. Analyze or interpretation of collected data b. Nutrition Diagnosis
  3. P: Identify the P roblem
  4. E: Determine the E tiology or cause
  5. S: S igns and symptoms c. Nutrition Intervention
  6. Define interventions and prescriptions
  7. Formulate goals and determine actions
  8. Implementing action d. Nutrition Monitoring and Evaluation
  9. Selects or identifies quality indicators
  10. Monitor and evaluate diagnosis completion Definition of documentation
  • Process of collecting, selecting, processing, and storage of information in the field of knowledge
  • the provision or collection of evidence from information such as pictures, quotations, newspaper, cuttings newspapers, and other reference materials Purpose of documentation
  • Means of communication
  • As a responsibility
  • For statistical information
  • Education
  • Source of research data
  • Service quality assurance
  • Source of data for sustainable nutrition care services
  • As a provider of data / patient history for further treatment from other health teams
  • Allows patients to make decisions about treatment to be given
  • Provides a record of diagnosis and treatment
  • As quality assurance
  • Communication a. Health care team b. Evidence of services provided c. Evidence for accreditation d. State audit Documentation requirements
  • Documentation is complete, clear, concise, objective, can be accountable and accurate
  • Notes: date, time, and service provider
  • No need for complete sentences but pronunciation must be correct
  • Avoid abbreviations that are unclear or have multiple meanings
  • Official word abbreviations are recorded in the abbreviation list
  • Avoid opinions, comments, criticism or debate between team members
  • Documentation in accordance with service time
  • At the end of the note: signature, profession, and name
  • Cannot be delegated Various forms of documentation
  1. DAP (Diagnosis, Assessment, Plan)
  2. DART (Data, Action, Response, Treatment)
  3. PIE (Problem, Intervention, Evaluation)
  4. PES (Problem, Etiology, Symptoms)
  5. IER (Intervention, Evaluation, Revision)
  6. HOAP (History, Observation, Assessment, Plan)
  7. SAP (Screen, Assess, Plan)
  8. SOAP (Subjective, Objective, Assessment, Plan) a) Subjective
  • Information extracted from the patient, family or person closest to the patient
  • Complaints perceived by the patient
  • Data regarding social and cultural psychology
  • Documentation:
    1. Date and time
    2. Collected data (data that has been collected and compared with existing standards)
    3. Patient perception
    4. Followed-up indicators Nutrition diagnosis
  • Data sources: Nutrition diagnosis terminology
  • Documentation:
  1. Date and time
  2. Nutrition diagnosis statement with PES ( P roblem, E tiology, S igns and symptoms) format Nutrition intervention
  • Data sources:
  1. Dietary guidelines
  2. Consensus result
  3. Latest and reliable research
  4. Patient educational materials
  5. Theories of behavior change
  • Documentation:
  1. Date and time
  2. Specific goals (interventions and expected outcomes)
  3. Patient acceptability
  4. Implementation Monitoring and evaluation
  • Data sources:
  1. Patient medical records
  2. Measurement (anthropometry, laboratory tests, and questionnaires)
  3. Interviews with patients, families, surveys, pre and post tests
  4. Evidence-based resources
  • Documentation:
    1. Date and time
    2. Measurement results from specific indicators
    3. Goals that have been achieved
    4. Factors affecting results
    5. Plan, monitoring, and follow-up